December 2016 EM Articles

*NNR THIS MONTH = 99

You'd have to read 2894 articles to find these 29 riveting reads.

*NNR - number needed to read

Comparing posteroanterior with lateral and anteroposterior chest radiography in the initial detection of parapneumonic effusions.
Am J Emerg Med. 2016 Dec;34(12):2402-2407. doi: 10.1016/j.ajem.2016.09.021. Epub 2016 Sep 14.
Spoon Feed: When patients are stable enough to send to radiology for a PA/Lateral CXR, do it.  The chance of missing significant pathology is much lower.

Favorable neurological outcomes by early epinephrine administration within 19 minutes after EMS call for out-of-hospital cardiac arrest patients.
Am J Emerg Med. 2016 Dec;34(12):2284-2290. doi: 10.1016/j.ajem.2016.08.026. Epub 2016 Aug 19.
Spoon Feed: If you're going to use epi in arrest, sooner is better.  But not too soon.  Recall that epi given within 2 minutes of defibrillation of a shockable rhythm was associated with worse outcome.

Determination of the chest wall thicknesses and needle thoracostomy success rates at second and fifth intercostal spaces: a cadaver-based study.
Am J Emerg Med. 2016 Dec;34(12):2310-2314. doi: 10.1016/j.ajem.2016.08.038. Epub 2016 Aug 20.
Spoon Feed: Based on this cadaver study, a 5cm catheter should be highly successful for needle decompression at either the 2nd ICS MCL or 5th ICS MAL.

Multiple Past Concussions in High School Football Players: Are There Differences in Cognitive Functioning and Symptom Reporting?
Am J Sports Med. 2016 Dec;44(12):3243-3251. Epub 2016 Jul 29.
Spoon Feed: Multiple concussions in high school caused increased symptoms but did not lead to poorer cognitive outcome.

Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial.
Ann Emerg Med. 2016 Dec 14. pii: S0196-0644(16)31244-6. doi: 10.1016/j.annemergmed.2016.10.014. [Epub ahead of print]
Spoon Feed: For analgesia, there was no difference in 10mg, 15mg, and 30mg of IV ketorolac.

Warning Symptoms Are Associated With Survival From Sudden Cardiac Arrest.
Ann Intern Med. 2016 Jan 5;164(1):23-9. doi: 10.7326/M14-2342. Epub 2016 Dec 22.
Spoon Feed: Patients with sudden cardiac arrest often had symptoms of chest pain or dyspnea in the 24 hours prior to arrest.

Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation.
Ann Intern Med. 2016 Dec 6;165(11):770-778. doi: 10.7326/M16-0402. Epub 2016 Sep 13.
Spoon Feed: No one survives if they have out of hospital arrest not witnessed by EMS, non-shockable initial rhythm, and no ROSC after 3 epinephrine doses.

Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties.
Ann Intern Med. 2016 Dec 6;165(11):753-760. doi: 10.7326/M16-0961. Epub 2016 Sep 6.
Spoon Feed: If you feel like most of your shift is spent on documentation, that's because it is.  Reducing the burden of documentation must become a priority.

Insurance Expansion and Hospital Emergency Department Access: Evidence From the Affordable Care Act.
Ann Intern Med. 2016 Dec 20. doi: 10.7326/M16-0086. [Epub ahead of print]
Spoon Feed: The ACA Medicaid expansion has had multiple effects: more ED visits, fewer uninsured patients in the ED, and perhaps more choices where to seek hospital care.

The Scientific Basis of Guideline Recommendations on Sugar Intake: A Systematic Review.
Ann Intern Med. 2016 Dec 20. doi: 10.7326/M16-2020. [Epub ahead of print]
Authors' Conclusion: "Guidelines on dietary sugar do not meet criteria for trustworthy recommendations and are based on low-quality evidence. Public health officials (when promulgating these recommendations) and their public audience (when considering dietary behavior) should be aware of these limitations."
Comment: Take this with a grain of salt.  It was funded by McDonalds, Pepsi, and Coke.

Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial.
BMJ. 2016 Dec 5;355:i6165. doi: 10.1136/bmj.i6165.
Spoon Feed: Use of an online decision aid helped patients with low risk chest pain better understand their condition and reduced admission rate without increasing risk for adverse outcome.  See the Chest Pain Choice decision aid.
Here is an example of a patient with a 0.9-1.7% risk of adverse coronary outcome after the ED workup.

Dispelling the nice or naughty myth: retrospective observational study of Santa Claus.
BMJ. 2016 Dec 14;355:i6355. doi: 10.1136/bmj.i6355.
AUTHORS' CONCLUSION: "The results of this study dispel the traditional belief that Santa Claus rewards children based on how nice or naughty they have been in the previous year. Santa Claus is less likely to visit children in hospitals in the most deprived areas. Potential solutions include a review of Santa's contract or employment of local Santas in poorly represented regions."

Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis.
BMJ. 2016 Dec 1;355:i6112. doi: 10.1136/bmj.i6112.
Spoon Feed: Pooling lots of studies, it looks like alpha blockers for larger kidney stones provide significant benefit with a low risk profile, similar to prior meta-analyses.

The Power of Flash Mob Research - Conducting a nationwide observational clinical study on Capillary Refill Time in a single day.
Chest. 2016 Dec 6. pii: S0012-3692(16)62563-1. doi: 10.1016/j.chest.2016.11.035. [Epub ahead of print]
AUTHORS' CONCLUSIONS: "Interobserver agreement on capillary refill time (CRT) is at best moderate. CRT measured at the distal phalanx yielded higher interobserver agreement compared to sternal CRT. FMR proved a valuable instrument to investigate a relative simple clinical question in an inexpensive, quick and reliable manner."

Functional and Exercise Limitations After a First Episode of Pulmonary Embolism: Results of the ELOPE prospective cohort study.
Chest. 2016 Dec 5. pii: S0012-3692(16)62555-2. doi: 10.1016/j.chest.2016.11.030. [Epub ahead of print]
Spoon Feed: PE may cause chronic dyspnea in almost half of affected patients.  As we learn more, we may be able to better target which people with submassive PE may benefit from fibrinolysis.  See this for an excellent review of pertinent studies.

Antipsychotic Use and Risk of Hospitalization or Death Due to Pneumonia in Persons With and Those Without Alzheimer Disease.
Chest. 2016 Dec;150(6):1233-1241. doi: 10.1016/j.chest.2016.06.004. Epub 2016 Jun 11.
AUTHORS' CONCLUSIONS: "Regardless of applied study design, treatment duration, or the choice of drug, the use of antipsychotic agents was associated with a higher risk of pneumonia. With observational data, we cannot fully rule out a shared causality between pneumonia and the use of antipsychotic agents, but the risk to benefit balance should be considered when antipsychotic agents are prescribed."

Clinic Blood Pressure Underestimates Ambulatory Blood Pressure in an Untreated Employer-Based US Population: Results From the Masked Hypertension Study.
Circulation. 2016 Dec 6;134(23):1794-1807.
AUTHORS' CONCLUSIONS: "Contrary to a widely held belief, based primarily on cohort studies of patients with elevated CBP, ABP is not usually lower than CBP, at least not among healthy, employed individuals. Furthermore, a substantial proportion of otherwise healthy individuals with nonelevated CBP have masked hypertension. Demonstrated CBP-aABP gradients, if confirmed in representative samples (eg, NHANES [National Health and Nutrition Examination Survey]), could provide guidance for primary care physicians as to when, for a given CBP, 24-hour ABP would be useful to identify or rule out masked hypertension.

Hospital Variation in Time to Epinephrine for Nonshockable In-Hospital Cardiac Arrest.
Circulation. 2016 Dec 20;134(25):2105-2114. Epub 2016 Dec 1.
AUTHORS' CONCLUSIONS: "Delays in epinephrine administration following in-hospital cardiac arrest are common and variy across hospitals. Hospitals with high rates of delayed epinephrine administration had lower rates of overall survival for in-hospital cardiac arrest attributable to nonshockable rhythm. Further studies are needed to determine whether improving hospital performance on time to epinephrine administration, especially at hospitals with poor performance on this metric, will lead to improved outcomes."

Duration of Prehospital Cardiopulmonary Resuscitation and Favorable Neurological Outcomes for Pediatric Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study.
Circulation. 2016 Dec 20;134(25):2046-2059. Epub 2016 Oct 24.
Spoon Feed: For pediatric arrest, prehospital CPR duration of 42 minutes is the time at which the probability of favorable neurological recovery is < 1%.

Association Between Duration of Resuscitation and Favorable Outcome After Out-of-Hospital Cardiac Arrest: Implications for Prolonging or Terminating Resuscitation.
Circulation. 2016 Dec 20;134(25):2084-2094. Epub 2016 Oct 19.
AUTHORS' CONCLUSIONS: "Shorter resuscitation duration was associated with likelihood of favorable outcome at hospital discharge. Subjects with favorable case features were more likely to survive prolonged resuscitation up to 47 minutes."

Clinical relevance of pharmacist intervention in an emergency department.
Emerg Med J. 2016 Dec 5. pii: emermed-2015-204726. doi: 10.1136/emermed-2015-204726. [Epub ahead of print]
Spoon Feed: PharmDs in the ED are a good thing.  We like ours!

Mid-arm circumference can be used to estimate weight of adult and adolescent patients.
Emerg Med J. 2016 Dec 19. pii: emermed-2015-205623. doi: 10.1136/emermed-2015-205623. [Epub ahead of print]
Spoon Feed: A great way to estimate the weight of an adolescent or adult is this formula.  Weight (kg) = 4 x MAC (cm) - 50.  My MAC is 30cm, which should make me 70kg.  Would that this were true...alas.

Safety and Efficacy of the "Easy Internal Jugular (IJ)": An Approach to Difficult Intravenous Access.
J Emerg Med. 2016 Dec;51(6):636-642. doi: 10.1016/j.jemermed.2016.07.001. Epub 2016 Sep 19.
Spoon Feed: In patients who need quick IV access, the IJ is an option.

Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents.
JAMA. 2016 Dec 20;316(23):2504-2514. doi: 10.1001/jama.2016.17396.
Spoon Feed: Physical rest after concussion appears to be unhelpful, even harmful, in children and young people after concussion.  This is a major paradigm shift.

Associations Between Hydration Status, Intravenous Fluid Administration, and Outcomes of Patients Infected With Shiga Toxin-Producing Escherichia coli: A Systematic Review and Meta-analysis.
JAMA Pediatr. 2016 Nov 28. doi: 10.1001/jamapediatrics.2016.2952. [Epub ahead of print]
Spoon Feed:  Early, IV fluid administration benefits patients with HUS and drastically reduces the odds of oliguria, need for dialysis, and death.  A word of caution from one who has made mistakes, start slowly: 5 or 10mL/kg.  You don't know if they are already in renal failure and oliguric.  Such patients can easily get volume overloaded.

Syphilis.
Lancet. 2016 Dec 16. pii: S0140-6736(16)32411-4. doi: 10.1016/S0140-6736(16)32411-4. [Epub ahead of print]
Spoon Feed: This is a good review of this STI.

Shortened Antimicrobial Treatment for Acute Otitis Media in Young Children.
N Engl J Med. 2016 Dec 22;375(25):2446-2456. doi: 10.1056/NEJMoa1606043.
Spoon Feed: For kids 6 - 23 months with acute otitis media, 10 days of antibiotic therapy is better than 5 days.

Importance of Urine Dipstick in Evaluation of Young Febrile Infants With Positive Urine Culture: A Spanish Pediatric Emergency Research Group Study.
Pediatr Emerg Care. 2016 Dec;32(12):851-855.
AUTHORS' CONCLUSIONS: "It might be inadequate to use a threshold of 50,000 cfu/mL to consider a urine culture as positive in young febrile infants given the fact that it would misdiagnose several UTIs."

Sweet Solutions to Reduce Procedural Pain in Neonates: A Meta-analysis.
Pediatrics. 2016 Dec 16. pii: e20160955. [Epub ahead of print]
Spoon Feed: Sucrose or sweet taste analgesia works well in neonates.

National Trends in the Prevalence and Treatment of Depression in Adolescents and Young Adults.
Pediatrics. 2016 Dec;138(6). pii: e20161878. Epub 2016 Nov 14.
Spoon Feed: Adolescent and young adult major depressive episodes are on the rise.